Provider Demographics
NPI:1942744008
Name:FASON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5570 SHAKESPEARE DR APT 206
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-0872
Mailing Address - Country:US
Mailing Address - Phone:901-331-7509
Mailing Address - Fax:
Practice Address - Street 1:5570 SHAKESPEARE DR APT 206
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-0872
Practice Address - Country:US
Practice Address - Phone:901-331-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN083216204343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)